System, method and apparatus for sternal closure

ABSTRACT

A system for closing together a first side of a sternum and a second side of the sternum of a patient. The system includes a first grommet to be disposed in the first side. The system includes a second grommet adapted to be disposed in the second side. The system includes a mechanism for placing a grommet into the sternum. The placing mechanism is adapted to hold the grommet for placement in the sternum. The system includes a first wire suture for insertion through the first and second grommets. The system includes a stop mechanism for allowing the placing mechanism to place a grommet into the sternum only in a desired location of the patient and any other portion of the patient is protected from damage by the placing mechanism during operation. A grommet. An approximator. A drill stop mechanism. A placement tool. A method of threading a wire suture through a hole in a sternum. A method of bringing together a first side of a sternum and a second side of the sternum.

CROSS-REFERENCE

This is a continuation application of U.S. patent application Ser. No.09/174,122 filed Oct. 16, 1998, now U.S. Pat. No. 6,045,572.

This application is related to U.S. patent application Ser. No.09/006,914 filed Jan. 13, 1998 entitled “A SYSTEM, APPARATUS AND METHODFOR CLOSING SEVERED BONE OR TISSUE OF A PATIENT” by James A. Magovern,incorporated by reference herein.

FIELD OF THE INVENTION

The present invention is related to the closure of hard or soft tissuethat has been separated. More specifically, the present invention isrelated to the closure of a sternum with the use of wire suturesinserted through grommets and placed into the sternum.

BACKGROUND OF THE INVENTION

There are various circumstances in which separated tissue of a patientneeds to be brought together so it can heal. Tissue is defined as bone,muscle or fascia that has been divided to gain access the thoraciccavity, mediastinum, or abdomen. For instance, in chest surgery, manytimes the sternum is separated so a surgeon can again gain access to thechest cavity and organs, muscle and tissue therein. After the surgeonhas finished his procedure regarding the chest cavity, the sternum needsto be closed. Key to the healing process of the sternum is the properstabilization and contact of the two severed sides together. Heretofore,there have been many techniques used to bring the separated sides of thesternum together and maintain them in contact so the healing process canoccur. However, these techniques generally limit the movement thepatient can experience without damaging or affecting the healingsternum. Furthermore, the process of introducing tools to bring theseparated sides of the sternum together can itself create risk or causedamage to the sternum.

The present invention provides for bringing the separate sides of thesternum together while minimizing damage to them and maintaining themwhile also allowing some flexibility and movement by the patient withoutdisturbing the healing process.

SUMMARY OF THE INVENTION

The present invention pertains to a system for closing together a firstside of a sternum and a second side of the sternum of a patient. Thesystem comprises a first grommet to be disposed in the first side. Thesystem comprises a second grommet adapted to be disposed in the secondside. The system comprises a mechanism for placing a grommet into thesternum. The placing mechanism is adapted to hold the grommet forplacement in the sternum. The system comprises a first wire suture forinsertion through the first and second grommets. The system comprises astop mechanism for allowing the placing mechanism to place a grommetinto the sternum only in a desired location of the patient and any otherportion of the patient is protected from damage by the placing mechanismduring operation.

The present invention pertains to a grommet. The grommet comprises afirst portion adapted to engage hard or soft tissue and be seated in thehard or soft tissue. The first portion has a hollow channel extendingthrough it. The grommet comprises a second portion which slides into thefirst portion through the hollow channel and forms a friction fit withthe first portion. The second portion has a hollow channel extendingthrough it.

The present invention pertains to an approximator. The approximatorcomprises a mechanism for engaging the ends of a wire suture. Theapproximator comprises a mechanism for tensioning the wire suture. Theengaging mechanism is connected to the tensioning mechanism. Theapproximator comprises a torque limiter in contact with the tensioningmechanism which limits the tension the tensioning mechanism can apply tothe wire suture.

The present invention pertains to a drill stop mechanism. The drill stopmechanism comprises a bottom plate adapted to fit underneath hard orsoft tissue to stop an object from penetrating past the bottom plate.The drill stop mechanism comprises a mechanism for holding the bottomplate in place about the hard or soft tissue.

The present invention pertains to a grommet placement tool. The grommetplacement tool comprises a handle. The grommet placement tool comprisesan elongate portion extending from the handle which engages and holds agrommet which is to be inserted into hard or soft tissue.

The present invention pertains to a method of threading a wire suturethrough a hole in a sternum. The method comprises the steps of insertinga wire passer through the hole so it extends in and through the hole andbeneath the sternum. Then there is the step of inserting a wire sutureinto the wire passer from beneath the sternum.

The present invention pertains to a method of bringing together a firstside of a sternum and a second side of the sternum The method comprisesthe steps of placing a drill stop mechanism under the first side of thesternum. Then there is the step of introducing an object into the firstside of the sternum over where the drill stop mechanism is located sothe object strikes the drill stop mechanism after it has passed throughthe first side of the sternum. Next there is the step of removing theobject from the first side of the sternum so a hole remains in thesternum. Then there is the step of placing a first grommet in the hole.Next there is the step of placing a second grommet in a hole in thesecond side of the sternum. Then there is the step of introducing a wiresuture into the first and second grommets. Next there is the step ofdrawing the ends of the wire suture which extend from the first andsecond grommets together so the first and second sides of the sternumcome together. Then there is the step of crimping the ends of the wiresuture.

The present invention pertains to a grommet for tissue. The grommetcomprises a first portion that is adapted to fix to the bottom of thetissue. The grommet comprises a second portion adapted to fit to the topof the tissue. Preferably, the first portion is threaded andself-tapping and the second portion is adapted to form a friction fitwith a hole in the tissue. The second portion has a rim which seats onthe top of the surface of the tissue.

The present invention pertains to a method for placing a grommet into asternum. The method comprises the steps of forming a hole in thesternum. Then there is the step of placing a first portion of thegrommet at the bottom of the sternum in the hole. Next there is the stepof placing a second portion of the sternum at the top of the sternum inthe hole.

The present invention pertains to a method of protecting a patient whenforming a hole in the patient. The method comprises the steps of placinga stop mechanism below a portion of the patient where the hole is goingto be formed but above the tissue of the patient which is not to havethe hole extend into it. Then there is the step of creating the hole.

BRIEF DESCRIPTION OF THE DRAWINGS

In the accompanying drawings, the preferred embodiment of the inventionand preferred methods of practicing the invention are illustrated inwhich:

FIG. 1 is a schematic representation of a system of the presentinvention.

FIG. 2 is a flow chart of a method of the present invention.

FIG. 3 is a perspective view of a sternum with grommets.

FIG. 4 is a schematic representation of a perspective view of a drillstop mechanism.

FIG. 5 is a schematic representation of a side view of the drill stopmechanism.

FIG. 6 is a schematic representation of a bottom view of a threadedinsert.

FIG. 7 is a schematic representation of a side in view of a threadedinsert.

FIG. 8 is a schematic representation of a top view of a threaded insert.

FIG. 9 is a schematic representation of a side view of a snap cap.

FIG. 10 is a schematic representation of a side view of a portion of asnap cap placement tool.

FIG. 11a is a schematic representation of a side view of a tool for thesnap cap placement tool.

FIG. 11b is a schematic representation of a front view of a tool for thesnap cap placement tool.

FIG. 12 is a schematic representation of the first and second tooth ofthe snap cap placement tool.

FIG. 13 is a schematic representation of a side view of the threadedinsert placement tool.

FIG. 14 is a schematic representation of a front view of theapproximator.

FIG. 15 is a schematic representation of a side view of theapproximator.

FIG. 16 is a schematic representation of a side view of the spool andanvil of the approximator.

FIG. 17 is a schematic representation of a perspective view of a wirepasser extending through the sternum.

FIGS. 18a, 18 b and 18 c are bottom, side and top views, respectively,of a first portion of an alternative embodiment of a grommet.

FIG. 19 is a schematic representation of the alternative embodiment of agrommet in hard tissue.

FIG. 20 is a schematic representation of the alternative embodiment ofthe grommet.

FIGS. 21a and 21 b are top and side views, respectively, of a secondportion of the alternative embodiment of the grommet.

FIG. 22 is a schematic representation of an alternative embodiment of agrommet placing mechanism.

FIG. 23 is a schematic representation of the alternative embodiment ofan approximator.

FIG. 24 is a schematic representation of an alternative embodiment of anapproximator.

FIGS. 25, 26 and 27 are schematic representations of a biodegradablegrommet.

FIG. 28 is a schematic representation of a side view of a crimp grommet.

FIG. 29 is a schematic representation of a perspective view of anuncrimped crimp grommet.

FIG. 30 is a schematic representation of a perspective view of a crimpedcrimp grommet.

FIG. 31 is a schematic representation of a hook grommet.

FIG. 32 is a schematic representation of a telescoping grommet which isnot extended.

FIG. 33 is a schematic representation of a telescoping grommet which isextended.

FIG. 34 is a schematic representation of a top view of a telescopinggrommet.

DETAILED DESCRIPTION

Referring now to the drawings wherein like reference numerals refer tosimilar or identical parts throughout the several views, and morespecifically to FIG. 1 thereof, there is shown a system 10 for closingtogether a first side 12 of a sternum and a second side 14 of thesternum of a patient. The system 10 comprises a first grommet 161 to bedisposed in the first side 12. The system 10 comprises a second grommet162 adapted to be disposed in the second side 14. The system 10comprises a mechanism 18 for placing a grommet 16 into the sternum. Theplacing mechanism 18 is adapted to hold the grommet 16 for placement inthe sternum. The system 10 comprises a first wire suture 201 forinsertion through the first and second grommets 16. The system 10comprises a drill stop mechanism 22 for allowing the placing mechanism18 to place a grommet 16 only in a desired location of the patient andany other portion of the patient is protected from damage by the placingmechanism 18 during operation.

Preferably, the placing mechanism 18 includes a drill mechanism 24 fordrilling a hole 26 into the sternum in which a grommet 16 is placed. Theplacing mechanism 18 preferably includes a grommet placement tool 28which inserts a grommet 16 into the hole 26 drilled by the drillmechanism 24 in the sternum. Each grommet 16 preferably comprises athreaded insert 36 that is adapted to fix to the sternum and a snap cap38 which fits inside the insert and through which the first wire suture201 extends.

Preferably, the system 10 includes an approximator 30 adapted fordrawing the first and second sides of the sternum together. The system10 preferably includes a crimper 32 for crimping the first wire suture201 together when it extends through the first and second grommets 16 inthe first and second sides of the sternum. Preferably, the system 10includes a wire passer 34 which extends through a grommet 16 tofacilitate the placement of the first wire suture 201 through thegrommet 16.

The present invention pertains to a grommet 16, as shown in FIGS. 6, 7,8 and 9. The grommet 16 comprises a first portion adapted to engage hardor soft tissue and be seated in the hard tissue, such as bone orcartilage, for instance of a sternum, or soft tissue. The first portionhas a hollow channel 33 extending through it. The grommet 16 comprises asecond portion which slides into the first portion through the hollowchannel 33 and forms a friction fit with the first portion. The secondportion has a hollow channel 37 extending through it. Preferably, thefirst portion is a threaded insert 36 which is self-tapping, and thesecond portion is a snap cap 38 having a bulge 39 in its outside surface40.

The present invention pertains to an approximator 30, as shown in FIGS.14, 15 and 16. The approximator 30 comprises a mechanism for engagingthe ends of a wire suture 20. The approximator 30 comprises a mechanismfor tensioning the wire suture 20. The engaging mechanism is connectedto the tensioning mechanism. The approximator 30 comprises a torquelimiter 42 in contact with the tensioning mechanism which limits thetension the tensioning mechanism can apply to the wire suture 20.

Preferably, the engaging mechanism includes a first spool 43 having aslot 44 and a second spool 45 having a slot 44. Each slot 44 is engagedto hold an end of the wire suture 20. The tensioning mechanismpreferably includes an axle 46 having a tensioning knob 47 at its top 48and a worm 49 at its bottom 50. The torque limiter 42 is disposed aboutthe axle 46 and between the knob 47 and the worm 49. There is a firstworm gear 51 and a second worm gear 52. Each worm gear is engaged withthe worm 49. The first spool 43 extends from the first worm gear 51 andthe second spool 45 extends from the second worm gear 52.

The present invention pertains to a drill stop mechanism 22, as shown inFIGS. 4 and 5. The drill stop mechanism 22 comprises a bottom plate 53adapted to fit underneath hard or soft tissue to stop an object frompenetrating past the bottom plate 53. The drill stop mechanism 22comprises a mechanism for holding the bottom plate 53 in place about thehard or soft tissue. Preferably, the holding mechanism includes a sideplate 54 which forms an angular relationship with the bottom plate 53and is attached to the bottom plate 53, and a top plate 55 which isslidably connected to the side plate 54 and is adapted to fit over thehard or soft tissue under which the bottom plate 53 is disposed.

The present invention pertains to a grommet placement tool 28, as shownin FIGS. 10, 11 a, 11 b, 12 and 13. The grommet placement tool 28comprises a handle 60. The grommet placement tool 28 comprises anelongate portion extending from the handle 60 which engages and holds agrommet 16 which is to be inserted into hard or soft tissue.

The elongate portion can include a collet stem 61 having a first plate62 and a second plate 64 which fits into a threaded insert 36 and an end65 which extends forward from the first and second plates which fitsinto the threaded insert 36 to hold the threaded insert 36. The handle60 can have a pin assembly 76 with a pin hole 26 and the elongateportion can include a holding tool 68 that attaches to the pin assembly76 through the pin hole 26. The holding tool 68 has a first tooth 69 andan opposing second tooth 70 which angle away from each other and extendfrom the head 71 of the tool 68. The first tooth 69 and second tooth 70are adapted to be inserted into a snap cap 38 of a grommet 16 to holdthe snap cap 38 by spring pressure in place.

The present invention pertains to a method of threading a wire suture 20through a hole 26 in a sternum, as shown in FIG. 17. The methodcomprises the steps of inserting a wire passer 34 through the hole 26 soit extends in and through the hole 26 and beneath the sternum. Thenthere is the step of inserting a wire suture 20 into the wire passer 34from beneath the sternum.

The present invention pertains to a method of bringing together a firstside 12 of a sternum and a second side 14 of the sternum. The methodcomprises the steps of placing a drill stop mechanism 22 under the firstside 12 of the sternum. Then there is the step of introducing an object,such as a drill, into the first side of the sternum over where the drillstop mechanism 22 is located so the object, such as a drill, strikes thedrill stop mechanism 22 after it has passed through the first side 12 ofthe sternum. Next there is the step of removing the object from thefirst side 22 of the sternum so a hole 26 remains in the sternum. Thenthere is the step of placing a first grommet 161 in the hole 26. Nextthere is the step of placing a second grommet 162 in a hole 26 in thesecond side 14 of the sternum. Then there is the step of introducing awire suture 20 into the first and second ah grommets. Next there is thestep of drawing the ends of the wire suture 20 which extend from thefirst and second grommets together so the first and second sides of thesternum come together. Then there is the step of crimping the ends ofthe wire suture 20.

The present invention pertains to a grommet for tissue. The grommetcomprises a first portion that is adapted to fix to the bottom of thetissue. The grommet comprises a second portion adapted to fit to the topof the tissue. Preferably, the first portion is threaded andself-tapping and the second portion is adapted to form a friction fitwith a hole in the tissue. The second portion has a rim which seats onthe top of the surface of the tissue.

The present invention pertains to a method for placing a grommet into asternum. The method comprises the steps of forming a hole in thesternum. Then there is the step of placing a first portion of thegrommet at the bottom of the sternum in the hole. Next there is the stepof placing a second portion of the sternum at the top of the sternum inthe hole.

The present invention pertains to a method of protecting a patient whenforming a hole in the patient. The method comprises the steps of placinga stop mechanism below a portion of the patient where the hole is goingto be formed but above the tissue of the patient which is not to havethe hole extend into it. Then there is the step of creating the hole.

In the operation of the invention, when the surgeon is ready to bringthe first side 12 and second side 14 of the sternum together to closethe sternum, as shown in FIG. 3, the surgeon or a designated individualor individuals take a drill hand unit and prepare to drill holes 26 intothe first side 12 and second side 14 of the sternum. The drill hand unitis connected to a drill power supply, such as a battery powered drill,to operate the drill hand unit. The drill hand unit is of standard issuewell known to one skilled in the art. The drill hand unit has insertedinto it a drill bit having a diameter of between 3.6-4.0 millimeters andpreferably about 0.15 inches (3.8 millimeters). The drill bit is ofstandard issue well down to one skilled in the art.

In preparation for drilling the first hole 26 through the first side 12of the sternum, a drill stop mechanism 22 is positioned about thesternotomy cut edge of the first side 12, as shown in FIGS. 4 and 5. Thedrill stop mechanism 22 is comprised of a top plate 55 and an opposingbottom plate 53 to the top plate 55. The bottom plate 53 extends from aside plate 54 as one piece and the side plate 54 forms essentially aright angle with the bottom plate 53. The bottom plate 53 is solid withno openings or slots or holes. The bottom plate 53 is what the drill bitstrikes after it has drilled through the first side 12 of the sternumand prevents the drill bit from drilling or striking any other part ofthe patient. Extending from the top plate 55 at essentially a rightangle in one continuous piece is a top plate edge 67 with ears 68.

The ears 68 are folded about the side plate 54 to cause the top plate 55to become captive with the side plate 54. The top of the side plate 54is folded down to capture the top plate 55 so it cannot be lifted up andoff of the side plate 54. The ears 68 prevent the top plate 55 frombeing moved sideways and removed from the side plate 54.

The top plate 55 has a top plate slot 66 which forms a target for thedrill bit to assure that the drill bit will always hit the bottom plate53, without having to make the bottom plate 53 any larger thannecessary. The top plate 55 moves up and down along the side plate 54through the ears 68 so the space between the top plate 55 and bottomplate 53 can be adjusted. When the drill stop mechanism 22 is placedabout the first side 12 of the sternum, the top plate 55 is slid upalong the side plate 54 to provide a greater thickness then thethickness of the first side 12 of the sternum so the bottom plate 53 canbe slid under the first side 12 of the sternum and the top plate 55 canbe slid over the top of the sternum until the sternotomy cut edge of thefirst side 12 of the sternum contacts the side plate 54 which stops thedrill stop mechanism 22 from further movement over the first side 12 ofthe sternum. The top plate 55 is then released and falls onto the topside of the first side 12 of the sternum, aligning a target for thedrill bit through the slot 66 of the top plate 55. The slot 66 of thetop plate 55 has gradations 81 along it to better identify the drillspot position for the drill bit to properly drill the hole 26 in thedesired position in the first side 12 of the sternum.

The process described for drilling the first hole 26 in the first side12 of the sternum is repeated for as many holes 26 as are deemedappropriate in the first side 12 of the sternum and the second side 14of the sternum. Typically, ten holes 26 are drilled in the sternum, fivein the first side 12 and five in the second side 14 (more forlarger/taller people) of the sternum, with each hole 26 in the firstside 12 of the sternum having an opposing hole 26 drilled in the secondside 14 of the sternum and in alignment with the corresponding hole 26in the first side 12 of the sternum. Typically, several inches willseparate each hole 26 in the respective sternum so enough of the sternumseparates the holes 26 to provide strong structural integrity betweenthe holes 26 and there will be no cracks or stress fractures between thedrill holes 26. The holes 26 are drilled approximately 1 cm from theincision and are of a standard size to fit the threaded inserts 36 ofthe grommets 16.

After the holes 26 are drilled into the first and second sides of thesternum, the grommets 16 comprised of threaded inserts 36 as shown inFIGS. 6, 7 and 8, and snap caps 38, as shown in FIG. 9, are introducedinto the holes 26 in the first and second sides of the sternum. Thethreaded inserts 36 and snap caps 38 of the grommets 16 are introducedinto the first and second sides of the sternum with two separate grommetplacement tools that are in use at the same time during the operation.One grommet placement tool 28, the snap cap placement tool 29, is tohold the snap caps 38 and a second grommet placement tool 28, thethreaded insert placement tool 27, is to hold the threaded inserts 36.During the operation, the surgeon's assistant loads a snap cap 38 on thesnap cap placement tool 29, as shown in FIGS. 10, 11 a, 11 b and 12,while the surgeon is screwing the threaded insert 36 with the threadedinsert placement tool 27 into a hole 26 in the first side 12 of thesternum. When the surgeon is finished screwing the threaded insert 36into the hole 26 in the first side 12 of the sternum, the surgeonswitches the now empty insert placement tool 27, as shown in FIG. 13,with a loaded snap cap placement tool 29 that is being held by theassistant. The surgeon then places the snap cap 38 into the threadedinsert 36 that the surgeon just screwed into the hole 26 in the firstside 12 of the sternum.

After the surgeon has switched the insert placement tool 27 with thesnap cap placement tool 29 and while the surgeon is placing the snap cap38 into the threaded insert 36, the assistant loads the threaded insert36 into the insert placement tool 27 just handed to the assistant. Bydoing this, when the surgeon finishes placing the snap cap 38 into thethreaded insert 36, the insert placement tool 27 is loaded and ready forthe surgeon to switch the now empty snap cap placement tool 29 with theloaded insert placement tool 27 to screw the next threaded insert 36into the next hole 26 in the first side 12 or second side 14 of thesternum, as the surgeon sees fit. The assistant then loads the snap capplacement tool 29 so the procedure is ready to occur again. This processis repeated until all of the grommets 16 are in place in all of theholes 26.

The threaded insert 36 is of a hollow cylindrical shaped bone screwwhich on its leading end is self tapping. The diameter of the threadedinsert 36 is 0.187 inches and the hole 26 drilled into the sternum is ofa slightly smaller diameter. The trailing end of the threaded insert 36has a screw driver slot 83 to receive the threaded insert placement tool27 so the threaded insert placement tool 27 can hold the threaded insert36 and screw the threaded insert 36 into the hole 26 in the sternum.Both the leading end and trailing end are chamfered so there are nosharp edges to tear or crack the sternum or cartilage in the sternum.The threaded insert 36 is made of 316L stainless steel. The threadedinsert 36 is provided in two lengths, 0.3 inches and 0.5 inches.

The snap cap 38 slides into the threaded insert 36 once the insert isscrewed into the bone. It is held in place by a friction fit. The snapcap 38 is hollow whose trailing end has a flange 84 which seats on thetrailing edge of the threaded insert 36 and the top of the sternum. Inapproximately the center of the snap cap 38 is a bulge 39 in itscylindrically shaped outer surface 40. The bulge 39 provides aspring-like effect to hold the snap cap 38 in the threaded insert 36 bya friction fit. The bulge 39 is achieved in the snap cap 38 bycompressing the snap cap 38 in its axial direction by known techniques.

The threaded insert placement tool 27 has a screw driver handle 60 witha collet stem 61 that is made of stainless steel. The collet stem 61 hasa first plate 62 and a second plate 64 which acts as a screw driver headand fits into the screw driver slot 83 of the threaded insert 36.Extending forward from the blades is an end 65 that angles inwards tofit into the hollow center of the threaded insert 36 to further assistin holding the threaded insert 36 to the collet stem 61. The center ofthe collet stem 61 is hollow. When the handle 60 is turned, the firstand second blades of the collet stem 61 are also turned, which resultsin the threaded insert 36 being turned and consequently screwed into thebone or cartilage around the hole 26 as the threaded insert placementtool 27 is rotated.

The snap cap placement tool 29 is comprised of a handle 60 with a pinassembly 76 and a holding tool 68 that attaches to the pin assembly 76through the pin hole 67. The tool 68 has a first tooth 69 and anopposing second tooth 70 which angle away from each other and extendfrom the head of the tool. The first tooth 69 and second tooth 70 aresqueezed together upon insertion into the hollow center of the snap cap38. By the first tooth 69 and second tooth 70 being squeezed together, aspring pressure from the first tooth 69 and second tooth 70 trying toexpand back to their equilibrium position is created against the insidesurface of the snap cap 38. This spring pressure serves to hold the snapcap 38 on the first tooth 69 and second tooth 70 of the snap capplacement tool 29 and if necessary the head 71 pushes against the snapcap 38 during placement to push the snap cap 38 into the threaded insert36. The spring pressure is less than the friction fit force created bythe bulge 39 of the snap cap 38 against the interior of the threadedinsert 36 once the snap cap 38 is inserted into the threaded insert 36.When the snap cap placement tool 29 is withdrawn after the snap cap 38has been inserted into the threaded insert 36, and there is nothing todrive against the snap cap 38, such as the head 71 when the snap cap 38is being inserted into the threaded insert 36, the snap cap 38 is heldin place in the threaded insert 36 and the snap cap placement tool 29separates from the snap cap 38.

In an alternative preferred embodiment of the grommet and referring toFIGS. 19 and 20, the grommet is comprised of a first portion 90 which isthreaded and self-tapping and a second portion 91 which is adapted toform a friction fit with a hole in the sternum. The second portion 91has a rim 92 which seats on the top of the surface of the sternum. Thesecond portion 91 has a tube 93 extending down into the hole which formsthe friction fit from the rim 92. The first and second portions are madeof stainless steel. Alternatively, the second portion can also bethreaded.

Placement occurs similarly to the embodiment of the grommet describedabove. With this embodiment of the grommet, the grommet placement tool28 also includes a threaded insert placement tool 27 which holds thefirst portion 90 of the grommet. With the it first portion 90 loaded onthe threaded insert placement tool 27, the surgeon screws the firstportion 90 into the hole and down to the bottom of the hole 26. Thesurgeon can tell when the first portion 90 has reached the bottom of thehole 26 in the sternum by simply placing his finger on the hole 26 underthe sternum and feeling the first portion 90 contact his finger as itreaches the bottom of the sternum. The surgeon then lifts the threadedinsert placement tool 27 out of the hole 26, with the first portion 90remaining threaded into the sternum in the hole 26.

The surgeon then hands the empty threaded insert placement tool 27 tothe surgeon's assistant and takes a second portion 91 placement tool 29,which is essentially the same as the snap cap placement tool 29, that isloaded with the second portion 91. The surgeon inserts the tube 93 ofthe second portion 91 into the hole 26 and firmly and carefully appliesforce downward with the second portion 91 placement tool 29 on thesecond portion 91, causing the second portion 91 to penetrate into thehole 26 and form a friction fit with the hole 26. The second portion 91will continue to penetrate into the hole until the rim 92 seats onto thesternum surface, causing the second portion 91 to stop moving into thehole.

The first portion 90 protects the bottom of the sternum from the wiresuture rubbing or tearing the sternum when tension is placed on the wiresuture 20. Similarly, the second portion 91 protects the top of thesternum from the wire suture rubbing or tearing the sternum when tensionis placed on the wire suture. The two critical locations on the sternumin regard to the wire suture are the top of the sternum where the wiresuture 20 bends and the bottom of the sternum with the wire suture 20bends and can put localized force on the sternum at the bending pointwhere the force it from the wire suture 20 is essentially against thesternum. The wire suture 20 extending along the hole in the sternum doesnot put significant force on the sternum or cartilage within the sternumsince it does not bend and pull against the sternum when the wire sutureis tensioned.

Once the grommets 16 are in place, the wire sutures 20 are placedthrough the grommets 16-one wire suture 20 for each pair of grommets 16that are in alignment across from each other. The wire suture 20 is astandard stainless steel wire used for sternal closure. It is 316Lstainless steel suture USP size 5. The end of the wire suture 20 ispushed down through the grommet 16 on the first side 12 of the sternumand a wire passer 34 is pushed down through the corresponding grommet 16on the second side 14 of the sternum. The wire passer 34 is a smallhollow flexible tube that is inserted through the grommet 16 to assistthe surgeon in locating the hole 26 from the underside of the sternum.The end of the wire suture 20 that has passed through the grommet 16 inthe first side 12 of the sternum is now within the chest. The wiresuture 20 is then bent and brought across to the wire passer 34 where itis inserted into the end of the wire passer 34 that extends into thechest through the grommet 16 in the second side 14 of the sternum, asshown in FIG. 17. When passing the wire suture 20 from within thesternum through the grommet 16, the surgeon will simply insert the endof the wire into the wire passer 34 and feed it through to the top sideof the patient's sternum. Once the wire suture 20 is through, the wirepasser 34 is pulled up through the grommet 16 and along the wire suture20 until it is removed from the wire suture 20. Once the wire passer 34is removed, the wire suture 20 is left in place extending through bothgrommets 16. This process is repeated until wire sutures 20 have beenplaced through each pair of grommets 16 in the sternum.

Each wire suture 20, beginning at the top of the sternum, is thentensioned (pulling the edges of the sternotomy together) using thesternal approximator 30, as shown in FIGS. 14, 15 and 16, and crimped.The sternal approximator 30 is used to tension the wire sutures 20 usedfor sternal closure. The sternal approximator 30 applies nearly equalforce to each end of the wire suture 20 for purposes of improvedstability of the closure.

The approximator 30 has a first spool 43 and an opposing second spool45. The end of the wire suture 20 extending from the grommet 16 in thefirst side 12 of the sternum is placed in the slot 44 in the secondspool 45. The slot 44 holds the end of the wire suture 20 in the spool.Similarly, the end of the wire suture 20 extending from the grommet 16in the second side 14 of the sternum is placed in the slot 44 and thefirst spool 43. In this way, the ends of the wire suture 20 cross overeach other and extend across an anvil 86 at the base of the approximator30. The anvil 86 is present to crimp the wire suture ends against tomore efficiently apply tension to the wire suture 20. The first spool 43extends from the first worm gear 51 of the approximator 30 and thesecond spool 45 extends from the second worm gear 52 of the approximator30. Each worm 49 gear engages a worm 49 that is disposed at the bottomof an axle 46 which extends through the center of the approximator 30.

At the top of the axle 46 is a tensioning knob 47 which is used torotate the axle 46 and thus the wire. Rotation of the worm 49 causes theworm gears 68 to rotate toward each other and tension the wire suture 20as each end of the wire suture 20 wraps around the respective spool asthey rotate. To ensure that the wire suture 20 is not tensioned morethen necessary and cause damage to the sternum, for instance by crushingeach side of the sternum together, a torque limiter 42 is disposedbetween the tensioning knob 47 and the frame 88 of the approximator 30.The tensioning knob 47 cannot rotate past the torque limiter 42, hencecontrolling the extent the knob can be tensioned. The free ends of thewire suture 20 are then crimped together, for instance with a plierswhich grips the ends and is than rotated. Any additional unnecessarylength of wire suture 20 is then cut and the crimped ends of the wiresuture 20 are then folded down upon the sternum. Closure of thesuperficial incision then proceeds normally.

When the tensioning is complete and the action of the approximator 30 onthe wire suture 20 has caused each end of the wire suture 20 to bepulled together and thus each end of the sternum through which each endof the wire suture 20 extends, the tensioning knob 47 is rotated in theopposite direction to unwind the ends of the wire suture 20 from thespool. When the ends of the wire suture 20 are completely unraveled fromthe spools, each end of the wire suture 20 is removed from the slot 44it is in of the spool. The tension on the wire suture 20 that is throughthe grommets 16 and within the chest relaxes somewhat but the sides ofthe sternum remain in place since there is little force present toseparate each side of the sternum. The presence of the grommets 16serves to protect the sternum from the wire suture 20 tearing or rubbingagainst it during the tensioning process and during the healing processwhere movement of the patient can create forces on each side of thesternum which would cause the sternum to separate were it not for thewire sutures 20 in place.

The presence of individual grommets as anchoring points through whichthe wire sutures extend, serves to allow the patient flexibility to movewhile minimizing the risk of tearing the healing incision. Each grommetis independent of any other grommet so no forces are created between thegrommets that would contribute to injuring the patient when the patientmoves. only the individual wire sutures connect two grommets, but thewire suture inherently allows for some movement while still providingstructural support to maintain the two sides of the sternum together.

Referring to FIG. 22, there is shown an alternative embodiment of theplacing mechanism. The grommet is placed on the tips 101 of the placingmechanism. The base 102 of the placing mechanism is inserted under thesternum and then the grips 103 are squeezed together to introduce thegrommet into the sternum.

FIG. 23 shows an alternative embodiment of an approximator. In thisembodiment, there is a torque gauge 110 that is disposed on a threadedshaft 112. When the torque gauge 110 is rotated, clamps 114 are closedtogether, pulling wires that have been inserted through holes 116 in theclamps. The torque gauge 110 reveals the level of tension on the wiresuture 20 being pulled together.

FIG. 24 shows another alternative embodiment of an approximator. Thewire suture 20 is connected to two respective clamps 121. A handle 125is rotated on a rack and opinion gear 126 causing the wire suture 20 tobe tensioned.

FIG. 25 shows an assembled biodegradable grommet 150. The biodegradablegrommet can be made from polyglycolide. The grommet 150 is comprised ofa male piece 151 shown in FIG. 26 and a female piece 152 shown in FIG.27.

In another embodiment of a grommet, there is shown in FIGS. 28, 29 and30 a side view of a crimp grommet 205, perspective view of an uncrimpedcrimp grommet 205, and a crimped view of a crimp grommet 205. The crimpgrommet 205 is inserted into a hole and then pliers grip the top 206 andbottom 207 of the uncrimped crimp grommet 205. The pliers are squeezedclosed causing the crimp grommet to crimp along pre-cuts in the body ofthe crimp grommet.

FIG. 31 shows another embodiment of a grommet, a hook grommet 210. Thehook grommet 210 is forced into a hole. Due to the hooks 211 angling up,the hook grommet 210 can move down, but if it is attempted to be movedup, the hooks 211 catch on the cartilage or hard tissue, preventing itfrom doing so.

FIGS. 32 and 33 show a telescoping grommet 220 made of a threaded malepiece 221 inside a female piece 222 which is also threaded. Theassembled male and female pieces are screwed into a hole by way of a hexsocket 224 shown in FIG. 34, in the female piece 222 which extendsbeyond the male piece 221. A socket wrench disposed in the socket 224 isrotated until the female piece 222 is in place. Then the male piece 221through its own hex socket is threaded through the female piece 222 tofurther extend it into the hard tissue, such as the sternum.

Although the invention has been described in detail in the foregoingembodiments for the purpose of illustration, it is to be understood thatsuch detail is solely for that purpose and that variations can be madetherein by those skilled in the art without departing from the spiritand scope of the invention except as it may be described by thefollowing claims.

What is claimed is:
 1. A system for closing together a first side of asternum and a second side of the sternum of a patient comprising: afirst grommet adapted to be disposed in the first side, the firstgrommet having a top having a flange, the flange of the first grommetadapted to be seated on the top surface of the first side; a secondgrommet adapted to be disposed in the second side, said second grommethaving a top having a flange, said flange of the second grommet adaptedto be seated on the top surface of the second side, each grommetcomprises a first portion having the top having the flange that isadapted to seat to the top surface of the respective side of the sternumand a second portion adapted to seat to the respective side of thebottom of the sternum, the second portion separate and independent fromthe first portion; and a first wire suture for insertion through thefirst and second grommet, the first wire suture extends through thefirst and second portions.
 2. A system as described in claim 1 includinga mechanism for placing the first or second grommet into the sternum,the placing mechanism adapted to hold the first and second grommet forplacement in the sternum.
 3. A system as described in claim 2 whereinthe placing mechanism includes a drill mechanism for drilling holes intothe sternum in which the first or second grommets are placed.
 4. Asystem as described in claim 3 wherein the placing mechanism includes agrommet placement tool which inserts the first or second grommet intothe holes drilled by the drill mechanism in the sternum.
 5. A system asdescribed in claim 4 including a crimper for gripping the first wiresuture together when it extends through the first and second grommets inthe first and second side of the sternum.
 6. A system as described inclaim 5 including a wire passer which extends through the first grommetto facilitate the placement of the first wire suture through the firstgrommet.
 7. A system as described in claim 1 wherein the first andsecond grommets are made of stainless steel.
 8. A system as described inclaim 1 wherein the second portion of the first grommet has a top havinga flange, the flange of the top of the second portion of the firstgrommet adapted to seat to the bottom of the first side; and the secondportion of the second grommet has a top having a flange, the flange ofthe top of the second portion of the second grommet adapted to seat tothe bottom of the second side.
 9. A system as described in claim 8wherein each portion of each grommet is adapted to extend into therespective side.
 10. A system as described in claim 9 wherein eachportion of each grommet is adapted to fix to the respective side.
 11. Amethod as described in claim 10 wherein the bringing step includes thestep of pulling the wire suture essentially in a parallel direction withrespect to the top surface of the sternum.
 12. A method for closingtogether a first side of a sternum and a second side of the sternum of apatient comprising the steps of: inserting a first grommet into thefirst side until a flange at the top of a first portion of the firstgrommet seats onto the top of the first side and a second portion of thefirst grommet seats adjacent the bottom of the first side, the secondportion separate and independent from the first portion of the firstgrommet; inserting a second grommet into the second side until a flangeat the top of a first portion of the second grommet seats onto the topof the second side and a second portion of the second grommet seatsadjacent the bottom of the second side, the second portion separate andindependent from the first portion of the second grommet; threading awire suture having a first end and second end through the first grommetand the second grommet; bringing the first side and second sidetogether; and securing the first and second end of the wire suturetogether.